One out, one in

To accompany #7daysofaction (see here for more details and stories of people’s horrendous experiences at the hands of inpatient services https://theatuscandal.wordpress.com/ ), this week I’m writing a series of short blogposts looking at the statistics we have about inpatient services for people with learning disabilities in England.

This post looks at who is being ‘admitted’ to inpatient services for people with learning disabilities in England, and who is either being discharged (lovely word, not) or ‘transferred’ to another hospital of some kind. This information has only started to be collected in the Assuring Transformation dataset (see here for the latest informationhttp://www.hscic.gov.uk/catalogue/PUB20499 ). This is collected and collated monthly by the Health and Social Care Information Centre from reports by health service commissioners of inpatient services in England (Clinical Commissioning Groups and NHS England specialist commissioners), and has now been collected consistently for just over a year.

Every month commissioners report who has gone into (or moved between) inpatient services, and who has moved out of (or been moved to other) inpatient services. I’ve simply added up the monthly figures for the 13 months we have the information, from March 2015 to March 2016. Some of the numbers won’t quite add up, as the numbers are rounded up or down to the nearest 5 people, and numbers in any months less than 5 people are not reported.

First up, how many people moved into or between inpatient services from March 2015 to March 2016?

Taking people transferring across from one inpatient service to another, in total 415 people were transferred into an inpatient service from another inpatient service over these 13 months (around 32 people per month, and almost a quarter (22%) of all ‘admissions’). At least 45 people were moving to somewhere with an increased security level, at least 170 people were moving to somewhere with a decreased security level, and at least 165 people were moving to somewhere at the same level of security.

In total, 1,450 people were admitted into inpatient services from March 2015 to March 2016 (over three-quarters, 78%, of all ‘admissions’). For 1,200 people, this was their first admission to inpatient services for at least a year (and maybe their first admission to an inpatient service ever). 250 people were coming into an inpatient unit within a year of their last time in an inpatient unit.

Where are people living at the time they are admitted (or transferred) into an inpatient service? The Assuring Transformation dataset keeps a record of where people had moved from into their current inpatient service. So, of everyone living in an inpatient service in March 2016, almost a quarter (22%) of people had come from their ‘usual place of residence, just 1% of people from a ‘temporary place of residence’, and 7% of people from residential care. 14% of people had come from a ‘penal establishment’ and 2% from an ‘other hospital’ (such as a general acute hospital). Over half of people, however, had moved from another learning disability inpatient service, mostly commonly an Assessment and Treatment Unit (48%) and less commonly from a secure forensic inpatient service (5%).

Three things occur to me from this information. First, there is a lot of ‘churn’ within the inpatient service system, with people moved around between inpatient services for reasons that are not immediately obvious. Second, although up to 3,000 people with learning disabilities are in inpatient services at any one time, over the course of a year many more people with learning disabilities (around 4,000 people?) are spending some time in an inpatient unit. Third, much, much more needs to be done to support people so they don’t need to go into inpatient services in the first place. For example, is the 14% of people coming into inpatient services from penal establishments a function of tightening eligibility criteria for social care services and reduced support for people and families, and are these people likely to be coming out of inpatient services any time soon?

As well as looking at who is coming into inpatient services, we can also look at how many people have left inpatient services over the same time period (although the numbers don’t exactly match).

Over the 13 months from March 2015 to March 2016, 455 people were reported to have transferred from an inpatient setting to another hospital, principally low secure services (at least 125 people), various forms of ‘rehab’ inpatient service (at least 105 people), ‘classic’ Assessment and Treatment Units (at least 50 people), and medium secure services (at least 45 people).

Over the same time period, 1,405 people were discharged from inpatient services into ‘community settings’ (on average, 108 people every month). People were commonly moving into residential care (at least 455 people), supported housing (445 people), their family home (with support, 345 people), and independent living (130 people).

Overall, this reinforces how many people are churned around the inpatient service system. It also explains why the length of stay for people in their current community inpatient unit is much shorter than people’s total length of continuous stay in inpatient services.

So, according to the 2015 Learning Disability Census, the median length of stay for people in their current inpatient unit was 554 days (or around a year and a half) – their average length of stay (due to that pesky ‘negative skew’ of some people living inpatient units for years and years) was 1,203 days (or well over 3 years). 

People’s total length of continuous stay in inpatient services was much longer, with a median of 861 days (well over 2 years) and an average of 1,794 days (almost 5 years). At the end of September 2015, 400 people (13% of all people in inpatient units) had been continuously in inpatient units for more than 10 years – to be fair, this is a reduction from the 540 people in this position in September 2014. The graphs below (come on, I can’t do a blogpost without any graphs) show this information in more detail.

Finally, the information on discharges from inpatient services shows that people can be and are moving out from inpatient services into a range of community-based alternatives (although we must always be mindful of the Daisy Unit scenario – I am unclear whether people moving into the Daisy Unit would count as moving into community-based residential care using these categories). A wide range of individualised, community-based support options can be done for people moving out of inpatient services. Wouldn't it be great if these options were there for people earlier, so they wouldn't ever be anywhere near an inpatient unit?